Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services
- Amanda Borsky ([email protected]) is a dissemination and implementation adviser in the Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality (AHRQ), in Rockville, Maryland.
- Chunliu Zhan is a health scientist administrator at AHRQ.
- Therese Miller is deputy director of the Center for Evidence and Practice Improvement, AHRQ.
- Quyen Ngo-Metzger is scientific director, US Preventive Services Task Force Program, Center for Evidence and Practice Improvement, AHRQ.
- Arlene S. Bierman is director of the Center for Evidence and Practice Improvement, AHRQ.
- David Meyers is chief medical officer at AHRQ.
As of 2015, only 8 percent of US adults ages thirty-five and older had received all of the high-priority, appropriate clinical preventive services recommended for them. Nearly 5 percent of adults did not receive any such services. Further delivery system–level efforts are needed to increase the use of preventive services.
Receiving recommended clinical preventive services can help maintain good health and save lives. Most prior assessments have focused on the receipt of specific services (such as rates of colorectal cancer screening or flu vaccination)1,2 or domain-specific composite measures (such as cancer screenings or cardiovascular care).1–4 These measures fail to take into account the multiple domains of preventive services that each person needs.
We developed a composite measure and a new survey designed to foster a systems approach to population health improvement. The measure and survey capture the use of all high-priority, appropriate clinical preventive services recommended for US adults. We found that as of 2015, only 8 percent of adults ages thirty-five and older had received all of the services recommended for them (exhibit 1).
Study Data And Methods
Our study data came from the Preventive Services Self-Administered Questionnaire (PSAQ) of the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey (MEPS). The PSAQ was fielded during panel 18, round 5, of the 2014 MEPS in the period January–May 2015. Among the 2,759 adults ages thirty-five and older who were eligible to complete the PSAQ, 2,186 did so—for an unweighted response rate of 79.2 percent.
The survey development process included expert review by survey methodologists and the use of focus groups and cognitive, usability, and field testing. To further establish validity, survey questions similar to those collected in the standard MEPS–Household Component were compared to questions in the PSAQ and overall were found to have high concordance.
The PSAQ asks questions about the receipt of fifteen high-priority clinical preventive services that were identified with input from an expert National Steering Committee according to the following criteria: The services were evidence based (that is, they had an A, B, or D grade recommendation from the US Preventive Services Task Force or a recommendation from the Advisory Committee on Immunization Practices) and clinically important (that is, relevant and actionable, so that the results can be used to improve the quality of care). The reference time period for each preventive service corresponds to the respective task force or committee recommendation (for example, during the past twelve months). The PSAQ survey and documentation are available on the MEPS website5 and in online appendix A.6
The complete list of high-priority, appropriate clinical preventive services by age-sex group is in appendix B.6 This list includes two measures of overuse, recommended by the steering committee to account for the importance of avoiding low-value services. For asymptomatic men and women ages seventy-five and older, cervical and prostate cancer screening are not recommended by the US Preventive Services Task Force. Therefore, the survey measures assess the appropriate uptake of these recommendations—that is, the percentages of people who did not receive the services.
We dichotomized all measures according to whether or not a person got the service appropriately (which includes not getting the two overuse services), based on the respondent’s answers to the PSAQ. The number of appropriate services differed for each person based on age, sex, and medical history. On average, each person should have received ten services (minimum: 7; maximum: 13).
We created an all-or-none composite measure to capture whether a person received all high-priority, appropriate clinical preventive services for his or her age-sex group.2,3,7 The score on this composite measure can be interpreted as the percentage of people who have no gaps in the receipt of the services recommended for them.
We conducted all data analyses using SAS, version 9.4; SUDAAN, version 11.0.1; and appropriate sample weights to account for the complex sample design of MEPS. Bivariate Rao-Scott chi-square tests were conducted to test for statistical differences.
This study had limitations. First, the PSAQ is based on self-report, and respondents may have forgotten about receiving services or misremembered how long it had been since they received them. Both survey measures and clinical data have different strengths and limitations in assessing preventive services use. No comparison between the self-reported results and clinical records was conducted, so we could not verify the results’ accuracy. While all-or-none composite measures may set a high bar for quality improvement, they may also magnify measurement error by compounding misreporting of individual items.7
Second, while our results are nationally representative and the PSAQ had a strong response rate of 79.2 percent, the sample size may be too small for meaningful subgroup analysis. The questionnaire has been incorporated into the standard data collection process for MEPS and is to be fielded again in 2018. Data from a larger sample size would facilitate more analyses of disparities in receipt of clinical preventive services as well as changes over time.
Overall, 8 percent (95% confidence interval: 6.5, 9.5) of US adults had received all of the recommended high-priority, appropriate clinical preventive services (exhibit 1). For the composite measure, differences by sex and age were not significant.
Given the low percentage of the adult population that had received all of the services, we examined the percentages of services that people had received. Overall, 22.4 percent of people received 76–100 percent of their recommended preventive services (95% CI: 20.2, 24.6), and 16.3 percent received 0–25 percent of their recommended services (95% CI: 14.1, 18.5) (exhibit 2). Men were more likely than women to receive only 0–25 percent of the services (21.9 percent [95% CI: 18.5, 25.2] versus 11.3 percent [95% CI: 9.0, 13.5]; ).
Only 4.7 percent (95% CI: 3.6, 5.8) of adults received none of the recommended services (data not shown). Men were more likely than women to have received no recommended services (7.3 percent [95% CI: 5.2, 9.3] versus 2.4 percent [95% CI: 1.2, 3.6]; ).
Overall, the most commonly received preventive service for all respondents was blood pressure screening, at close to 90 percent, and the least commonly received service was zoster vaccination (against shingles), at less than 40 percent (exhibit 3). For the two measures of overuse, nearly 70 percent of the women ages seventy-five and older appropriately did not receive cervical cancer screening, but only about half of the men in that age group appropriately did not receive a prostate-specific antigen test.
|Women ages 35–64||75.5||75.5||—a|
|Women ages 75 and olderb||68.3||68.3||—a|
|PSA (men ages 75 and older)b||50.2||—a||50.2|
In general, for individual services used by both men and women, women were more likely than men to receive each individual service. These differences reached significance for blood pressure screening, cholesterol screening, obesity screening and counseling, and depression screening. The only service received more often by men than women was counseling on aspirin use. Additional analyses are available in appendix tables S1–S3.6
Results from the new Preventive Services Self-Administered Questionnaire, fielded in the first half of 2015, show that only 8 percent of Americans ages thirty-five and older reported having received all of the appropriate, high-priority clinical preventive services recommended for them, and nearly 5 percent reported having received none of them. The results also show that comprehensive preventive care is achievable: More than 20 percent of adults reported receiving more than 75 percent of the services.
The results are consistent with those of previous studies that have demonstrated large gaps in the receipt of individual clinical preventive services.1 However, no other known composite measure incorporates the diverse spectrum of preventive services included in the PSAQ, including screening, counseling, preventive medications, and vaccinations. One existing preventive services composite measure includes only five screening and vaccination services.2,3 Commonly known reasons for not getting appropriate preventive services include lack of health insurance; lack of a usual source of care; and gaps in provider capacity, including wait times.
Using the all-or-none composite measure and drilling down to the individual preventive services where performance gaps are widest could help health systems and practices target interventions to improve performance. As Thomas Nolan and Donald Berwick conclude, the all-or-none approach “raises the bar and illuminates excellence in a societal enterprise that should not be satisfied with partial credit or incomplete execution.”7(p1170)
We describe this composite measure as person-centered based on feedback from representatives on the National Steering Committee, who reminded us that being up-to-date on depression and cholesterol screening and then developing metastatic colon cancer should not be seen as receiving high-quality preventive care. People expect and deserve to receive all of the evidence-based clinical preventive services that are appropriate for them. This is a core premise in all-or-none composite measures.
There may be different reasons why people do not get what is recommended or do get what is not recommended, and the composite measure includes the appropriate use of both constructs. Overuse measures are included because services that are not indicated can cause harm. In a sensitivity analysis that excluded the overuse measures, we found that 8.3 percent (95% CI: 6.8, 9.8) of adults received all of the recommended services—a share that was not significantly different from our main result of 8.0 percent (data not shown).
This new questionnaire and composite measure were designed for use not only at the national level, but also at the system and practice level. Focusing on individual services in isolation is unlikely to generate meaningful improvement on the composite measure. Improvement requires system-level innovation, including population data analysis, useful clinical decision support, and optimal use of the entire health care workforce.
Health systems and individual practices can use the PSAQ survey and composite measure to assess the receipt of clinical preventive services among the people they serve. They can drill down and target quality improvement efforts based on observed disparities in care and on which services are most commonly not being received. Of course, quality improvement efforts to increase the receipt of recommended services may differ from those needed to discourage the receipt of inappropriate services. Health systems will need to select relevant quality improvement solutions and tailor them to local factors, as well as determining where improvements are needed most.
The PSAQ and composite measure will also be useful for monitoring the impact of national and local policy changes. For example, while the Affordable Care Act has increased the number of Americans who do not have any cost-sharing responsibilities for clinical preventive services, including those included in the composite measure, research has not yet explored the effects of these changes.
While the current analyses were limited by the sample size, the PSAQ is now a standard component of MEPS. This will allow monitoring of changes in the receipt of high-priority clinical preventive services over time, as well as providing more robust data for analysis.
Preliminary results from this study were presented at the Society for Prevention Research Conference, June 2, 2017, Washington, D.C.; and the North American Primary Care Research Group conference, November 20, 2017, Montreal, Quebec. The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of the Agency for Healthcare Research and Quality (AHRQ). No statement in this report should be construed as an official position of AHRQ or of the US Department of Health and Human Services. The authors appreciate the efforts of Bidong Liu, Yanling Zhao, and Zhengyi Fang (of Social and Scientific Systems, Inc.) in the data production and preparation of the exhibits; Steven R. Machlin and Pradip Muhuri (of AHRQ) in providing technical assistance; and Russ Mardon, Shannon Fair, Phuong Hoang, and Mary Masters (currently or formerly of Westat) and Wilson Pace and Brandon Combs (of the University of Colorado) in helping develop the Preventive Services Self-Administered Questionnaire.
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